Low Back Pain and Breathing Pattern Disorders

The respiratory musculature is closely linked to the lumbar spine, and there is evidence of an association between respiration and low back pain (LBP). A systematic review shows moderate support for the use of breathing exercises in the treatment of chronic, nonspecific low back pain¹. Another study has shown that the presence of a respiratory disease may be a risk factor for low back pain². A third review found a significant association between low back pain and breathing pattern disorders (BPD), including both pulmonary diseases and nonspecific breathing pattern disorders³. One proposed explanation is that suboptimal coordination of postural and respiratory functions in the core musculature may contribute to this association. A case–control study found that patients with chronic low back pain displayed more altered breathing patterns during motor control testing⁴.

Clinically Relevant Anatomy

Thorax is formed by the spine, ribs, and associated muscles. The diaphragm constitutes the floor of the thorax. The intercostal muscles connect the ribs, while the sternocleidomastoid and scalenes extend from the head and neck to the sternum and the upper ribs. The diaphragm has a direct connection to the spine.

Inspiratory muscles: external intercostals, diaphragm, sternocleidomastoid, and scalenes.

Expiratory muscles: internal intercostals and the abdominal muscles (at rest, expiration occurs passively)⁵⁶.

Epidemiology and Etiology

Breathing pattern disorders are multifactorial. Dysfunctional breathing (DB) is defined as chronic or recurrent changes in breathing patterns without a known medical cause, producing both respiratory and non-respiratory symptoms⁷. Individuals with respiratory problems are often more sedentary, which may lead to low back pain⁸. In addition, a sedentary lifestyle may result in poor posture, weakening of postural musculature, and muscle tension related to psychological stress—all of which contribute to the development of chronic low back pain⁹.

Clinical Presentation

The diaphragm and transversus abdominis play a key role in core stability, but their supportive function can be reduced when the low back and the respiratory musculature are simultaneously loaded. After approximately 60 seconds of hypercapnia, both the postural and dynamic function of the diaphragm and transversus abdominis are reduced¹⁰. Breathing training can mitigate the negative effects of breathing pattern disorders. One study suggests that breathing therapy may improve proprioception and thus be a useful adjunct in the treatment of low back pain⁹.

Symptoms of breathing pattern disorders (BPD) may include:

• Dizziness

• Chest pain

• Visual disturbances

• Feelings of unreality and panic attacks

• Nausea

• Reflux

• General fatigue

• Difficulty concentrating

• Dyspnoea with normal lungs

• Frequent yawning

• Hyperventilation

• Other symptoms: numbness, cold extremities, irritable bowel/bladder, “brain fog,” and paraesthesias

Differential Diagnoses

Breathing pattern disorders and low back pain may coexist with more serious conditions involving the heart, lungs, and abdominal organs. Other differential diagnoses:

• Brain injuries

• Stroke

• Asthma

• Gastrointestinal disorders

• Heart disease

• Other pulmonary conditions

Characteristics of breathing pattern disorders:

• Restlessness

• “Air hunger”

• Frequent sighing

• Rapid swallow rate

• Poor breath-holding capacity

• Poor lateral expansion of the lower thorax

• Shoulder elevation during inspiration

• Visible “string-like” sternocleidomastoid

• High respiratory rate

• Paradoxical breathing

• Nijmegen score ≥23⁷

• Low end-tidal CO₂ (below 35 mmHg)

• Symptom cluster: fatigue, pain, anxiety, cognitive complaints, irritable bowel or bladder

Outcome Measures

There are no standardized instruments that combine low back pain and breathing pattern disorders. The following can be used:

• Visual Analogue Scale (VAS) for pain

• Roland–Morris Disability Questionnaire (24 items) for disability

• SF-36 for general health status

• Postural stability (dynamic posturography or static force platform) to assess balance and proprioception before and after treatment¹¹.

Assessment

Examination of the low back should follow standard guidelines (see separate text on low back pain). Breathing pattern disorders are assessed using a combination of clinical examination, the Nijmegen Questionnaire, and capnometry.

Capnography: Measures the level of carbon dioxide in exhaled air (end-tidal CO₂) and has shown good agreement with arterial CO₂ measurement¹². Although capnography has documented validity for diagnosis, there is limited research on its therapeutic application¹³.

Nijmegen Questionnaire: An internationally validated, simple, non-invasive tool with high sensitivity (up to 91%) and specificity (up to 95%). It screens for acute and chronic hyperventilation by asking about symptoms such as¹⁰:

• Chest tightness

• Shortness of breath, rapid or deep breathing, difficulty taking a deep breath

• Feeling tense, tightness around the mouth, stiffness in fingers or arms, cold hands or feet

• Tingling in the fingers

• Bloating

• Dizziness

• Blurred vision

• Feeling of confusion or detachment from surroundings

Medical Management

Low back pain:The most commonly used medications for low back pain are NSAIDs, muscle relaxants, and opioid analgesics. A review from the American Pain Society and the American College of Physicians shows that several drugs have documented efficacy for short-term relief of both acute and chronic low back pain, though each has distinct risk profiles¹⁴. NSAIDs and muscle relaxants are effective for acute pain, while tricyclic antidepressants may be useful for chronic pain¹⁴. For mild to moderate pain, paracetamol may be considered due to a more favourable side-effect profile than NSAIDs. For severe pain, opioids may be an option to achieve sufficient pain relief and improved function despite potential adverse effects¹². The effect of medications on functional outcomes is limited, and more research is needed¹⁴.

Surgical treatment: May be indicated in disc herniation, spondylolisthesis, or spinal stenosis. A large follow-up study on patients with spondylolisthesis and spinal stenosis showed that surgical treatment provided better pain relief and function over four years compared with conservative care¹². Another study on disc herniation demonstrated that surgically treated patients had better outcomes at four years than those treated non-operatively¹³.

Breathing pattern disorders: In asthma, beta-agonists are the most commonly used medications for both children and adults. These agents are potent bronchodilators that open the airways, dampen inflammation, and provide rapid symptom relief. Inhalation is preferred because it offers better dose–response and faster onset¹². A four-year study investigated whether disease progression in patients with asthma or COPD could be slowed by adding inhaled steroids. For the first two years, patients received bronchodilators only; for the final two years, inhaled steroids were added. The results showed that steroids slowed disease progression, especially in asthma¹³.

Physiotherapy Management

Breathing training can reduce the negative effects of breathing pattern disorders on low back pain¹¹. Through verbal guidance and manual therapy, the physiotherapist helps the patient develop awareness and the ability to perceive and integrate breathing movements in the area where pain occurs¹⁴. One study suggests that breathing therapy may improve proprioception and serve as a useful adjunct in treating low back pain¹⁴.

Management of Breathing Pattern Disorders

Physiotherapists also treat patients with respiratory problems. The aims are to control breathlessness, improve or maintain mobility and function, promote secretion clearance, and strengthen cough. It can also be beneficial for musculoskeletal pain, postural dysfunction, and pain, as well as improving continence during coughing and forced expiration¹⁵.

Techniques include:

• Exercise testing

• Exercise programmes

• Secretion mobilisation

• Positioning

• Breathing techniques

General physiotherapy principles for breathing pattern disorders¹¹:

• Patient education about pathophysiology of the condition

• Self-observation of breathing patterns

• Return to an individual, physiological breathing rhythm: relaxed, rhythmic nasal–abdominal breathing

• Tailored tidal volume

• Focus on stress and bodily tension

• Posture

• Breathing during activity and movement

• Attention to clothing

• Breathing and speech

• Breathing and nutrition

• Breathing and sleep

• Breathing during acute episodes

Effect of Physiotherapy

A randomised clinical trial has shown that physiotherapy yields clinically relevant improvements in quality of life in patients with asthma, which is also considered a functional breathing disorder⁸. The British Thoracic Society has developed guidelines for physiotherapy in medical respiratory dysfunction¹⁶.

One study showed that eight weeks of inspiratory muscle training at 60% of 1RM in patients with low back pain led to significant increases in inspiratory muscle strength, improved postural control, and reduced pain¹¹.

Another study compared breathing therapy with standard physiotherapy and found that both groups had similar improvements in pain and function after 6–8 weeks¹⁷.

Therapeutic Exercises

“90/90 bridge with ball and balloon” can be used to optimise diaphragm function and the stabilising role of the core musculature. This technique includes 90° hip and knee flexion with a ball between the knees and balloon blowing. This position promotes lumbar flexion, posterior pelvic tilt, and rib depression, thereby optimising the “zone of apposition” and reducing overload in the low back¹⁸.

According to McLaughlin et al., breathing training may improve end-tidal CO₂, pain, and function in patients with neck or back pain¹⁹. Common findings in patients with breathing pattern disorders include high respiratory rate, low CO₂ levels, irregular breathing, and shallow chest breathing.

Examples of breathing techniques:

Abdominal breathing technique

Lie on your back with one hand on the chest and one on the abdomen. Inhale gently through the nose so that the abdomen rises. The goal is 6–10 deep, slow breaths per minute for 10 minutes daily to reduce heart rate and blood pressure⁹¹⁴.

Three-part breathing

Lie on your back with eyes closed. First fill the abdomen, then expand the ribs, and finally the upper chest. On exhalation, release the air in reverse order⁹¹⁴.

Inspiratory muscle training (with Powerbreathe KH1)⁷¹²:

• Exercise 1: Stand on one leg with the Powerbreathe in the mouth, arm raised. Maintain a neutral spine and an engaged “abdominal corset.” Bend forward and inhale forcefully. Repeat 2 sets of 15 repetitions.

• Exercise 2: Stand with feet shoulder-width apart, hold a cable handle in front of the shoulder. Keep the Powerbreathe in the mouth. Press the cable forward while inhaling forcefully. 2 sets of 15 repetitions.

• Exercise 3: Plank on toes and elbows with the Powerbreathe in the mouth. Maintain a neutral spine and engaged “abdominal corset.” Hold for 30 seconds. Progression: move one leg toward the body. 3 sets.

• Exercise 4: Supine bridge with the Powerbreathe in the mouth. Lift hips toward the ceiling, hold for 30 seconds. Progression: lift one leg. 3 sets.

References

1. Anderson BE, Bliven KC. The Use of Breathing Exercises in the Treatment of Chronic, Nonspecific Low Back Pain. Journal of sport rehabilitation. 2017 Sep;26(5):452-8.

2. Michelle D. Smith et al., “Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity”, Australian Journal of Physiotherapy, vol 52:1, pag 11 - 16.

3. Nele Beeckmans et al., “The presence of respiratory disorders in individuals with low back pain: A systematic review”, Manual Therapy, 2016, Vol 26, pag 77–86.

4. Roussel et al., “Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case–control study”, European Spine Journal, 2009, 18.7: 1066-1073

5. B.R. Johnson, W.C. Ober, C.W. Garrison, A.C. Silverthorn. Human Physiology, an integrated approach, Fifth edition. Dee Unglaub Silverthorn, Ph.D.

6. Theodore A. Wilson and Andre De Troyer. diaphragm Diagrammatic analysis of the respiratory action of the. J Appl Physiol 108:251-255, 2010. ; doi:10.1152/japplphysiol.00960.2009

7. Michelle D. Smith et al., “Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity”, Australian Journal of Physiotherapy, vol 52:1, pag 11 - 16

8. Gordon, Saul Bloxham et al., "A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain" Healthcare Multidisciplinary Digital Publishing Institute, 2016, p. 22

9. Schünke, M., Schulte, E., Schumacher, U., Voll,M., Wesker, K.& (2010). Anatomische atlas Prometheus.: lichaamswand - botten, banden en gewrichten. (Tweede druk). Houten: Bohn Stafleu van Loghum.

10. Richard Boulding et al., ”Dysfunctional breathing: a review of the literature and proposal for classification”, 2016, vol. 25 no. 141 287-294.

11. Tania CliftonSmith et al., “Breathing Pattern Disorders and physiotherapy: inspiration for our profession”, Physical Therapy Reviews, 2011, volume 16, no 1

12. Bulletin of the World Health Organization 2003;81:671-676

13. J. S. Gravenstein,Michael B. Jaffe,David A. Paulus. Capnography: clinical aspects : carbon dioxide over time and volume. Br. J. Anaesth. 94 (5): 695-696. doi: 10.1093/bja/aei539

14. Nele Beeckmans et al., “The presence of respiratory disorders in individuals with low back pain: A systematic review”, Manual Therapy, 2016, Vol 26, pag 77–86.

15. Roussel et al., “Altered breathing patterns during lumbopelvic motor control tests in chronic low back pain: a case–control study”, European Spine Journal, 2009, 18.7: 1066-1073.

16. Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, Harvey A, Hughes T, Lincoln M, Mikelsons C, Potter C. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. 2009 May 1;64(Suppl 1):i1-52.

17. Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic low-back pain, Alternative Therapies in Health and Medicine 2005 Jul-Aug;11(4):44-52 (1B)

18. Fernandes J, Chougule A. Effects of Hemibridge with Ball and Balloon Exercise on Forced Expiratory Volume and Pain in Patients with Chronic Low Back Pain: An Experimental Study. International Journal of Medical Research & Health Sciences. 2017;6(8):47-52.

19. McLaughlin L, Goldsmith CH, Coleman K. Breathing evaluation and retraining as an adjunct to manual therapy. Manual therapy. 2011 Feb 1;16(1):51-2.